Extra Vessels Reporting Form

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Extra Vessels Form

Extra vessels are taken during recovery of deceased or living donor organs with the intent to be used in organ transplantation only. Extra vessels are not connected to the organ. Extra vessels are subject to the same member requirements applying to the organ unless otherwise specified.

Per policy, transplant centers must report the final disposition of extra vessels to the OPTN within 7 calendar days of the vessel disposition.

Institution

Institution: Select the institution from a drop-down list. This is a required field.

Donor Information

Vessel donor ID: Enter the vessel donor ID. This is a required field.

Donor type: Verify the donor type.

Donor institution: Verify the donor institution.

Recovery date: Verify the recovery date.

Vessel Disposition

Vessel disposition: Select the vessel disposition method from a drop-down list.

Transplanted

Destroyed

Sent to another hospital

Other

If reporting Transplanted extra vessels, complete the following fields:

• Recipient SSN

• Recipient last name

• Recipient first name

You may search for the vessel transplant recipient by entering the information and clicking the Find Recipient button. A vessel recipient must be an organ transplant recipient and either transplanted at your hospital or currently being seen at your hospital. Select the recipient’s SSN from the list of results.

Note: Report an extra vessel transplant that was transplanted into the intended recipient, but was not documented at the time of Waitlist removals, as well as an extra vessel that was transplanted in the non-intended recipient at the same transplant center. Per policy, extra vessels from living donors can only be transplanted into the intended recipient for that living donor organ transplant.

Vessel transplant date: If the vessel was transplanted, enter the vessel transplant date.

Vessel destruction date: If the vessel was destroyed, enter the date of destruction.

Other specify text: Select Other to report the outcome of extra vessels that are not transplanted, destroyed, or shared between transplant hospitals.

Note: If an extra vessel (unattached to the organ) was sent to research, use this option and add a note to the additional comments text box.

Organ accompanied: Choose the type of organ accompanied. This refers to the donor organ that the vessel was packaged with when your hospital received the vessel, not sent. If the vessel did not come with any donor organ, then select Vessel sent alone.

Select hospital: If the vessel(s) was sent to another hospital, select all the hospitals the vessels were sent to from the list. If the vessel was received from another transplant hospital as a result of sharing, choose the appropriate hospital from the drop-down list.

Additional information: Provide any additional information if necessary.

Public Burden Statement: The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected].   

OPTN Restricted

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